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Section: Miscellaneous
Effective Date: January 01, 2020
Revised Date: January 01, 2020
Last Reviewed: November 14, 2019


Experimental/Investigational services are defined as a treatment, procedure, facility, equipment, drug, service or supply (“intervention”) that has been determined not to be medically effective for the condition being treated.

This policy addresses services considered to be experimental/investigational and, therefore, non-covered services.


Charges submitted for the services listed in this policy are denied as experimental/investigational. The determination for denial is based on ANY of the following reasons:

  • The intervention does not have Food and Drug Administration (FDA) approval to be marketed for the specific relevant indication(s); or
  • Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or
  • The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
  • The intervention does not improve health outcomes; or
  • The intervention is not proven to be applicable outside the research setting.

The following procedure codes are considered experimental/investigational and, therefore, non-covered. Scientific evidence of safety and efficacy has not been proven.

Procedure Codes

31647 31648 31649 31651 32994 33440 64454
64624 64625 90587 90689 91022 92145 93895
96931 96932 96933 96934 96935 96936 0100T
0111T 0174T 0175T 0198T 0200T 0201T 0202T
0207T 0219T 0220T 0221T 0222T 0263T 0264T
0265T 0266T 0267T 0268T 0269T 0270T 0271T
0272T 0273T 0278T 0329T 0330T 0333T 0335T
0338T 0339T 0342T 0356T 0358T 0381T 0382T
0383T 0384T 0385T 0386T 0396T 0397T 0400T
0401T 0405T 0408T 0409T 0410T 0411T 0412T
0413T 0414T 0415T 0416T 0417T 0418T 0421T
0422T 0423T 0424T 0425T 0426T 0427T 0428T
0429T 0430T 0431T 0432T 0433T 0434T 0435T
0436T 0437T 0439T 0440T 0441T 0442T 0443T
0444T 0445T 0451T 0452T 0453T 0454T 0455T
0456T 0457T 0458T 0459T 0460T 0461T 0462T
0463T 0465T 0469T 0470T 0471T 0472T 0473T
0475T 0476T 0477T 0478T 0479T 0480T 0484T
0485T 0486T 0487T 0488T 0489T 0490T 0491T
0492T 0493T 0497T 0498T 0499T 0505T 0506T
0507T 0508T 0512T 0513T 0515T 0516T 0517T
0518T 0519T 0520T 0521T 0522T 0523T 0525T
0526T 0527T 0528T 0529T 0530T 0531T 0532T
0533T 0534T 0535T 0536T 0541T 0542T 0543T
0544T 0545T 0546T 0547T 0548T 0549T 0550T
0551T 0552T 0553T 0554T 0555T 0556T 0557T
0558T 0559T 0560T 0561T 0562T 0563T 0564T
0565T 0566T 0567T 0568T 0569T 0570T 0571T
0572T 0573T 0574T 0575T 0576T 0577T 0578T
0579T 0580T 0581T 0582T 0583T 0002U 0012U
0021U 0024U 0025U 0035U 0038U 0039U 0041U
0042U 0043U 0044U 0058U 0059U 0061U 0062U
0063U 0064U 0065U 0066U 0077U 0080U 0083U
0091U 0092U 0093U 0095U 0105U 0106U 0107U
0108U 0110U 0121U 0122U 0123U 0124U 0125U
0126U 0127U 0128U 0139U 0143U 0144U 0145U
0146U 0147U 0148U 0149U 0150U A4563 K1001
K1002 L2006 L8608 L8701 L8702 Q0035 S3902
S8040 S9025

Outpatient HCPCS (C Codes)

C1734 C1824 C1839 C1982 C2596 C9250 C9758